Medico-legal principles in acute care

Manage now— do this, in order

• Resuscitate first: no form, relative or third party precedes airway, breathing and circulation — treatment delayed while a form was sought is the commonest avoidable medico-legal disaster in acute care.
• Optimise before you judge: correct hypoglycaemia (adults 100–200 mL of 10% glucose IV, or glucagon 1 mg IM if no access; children 2 mL/kg of 10% glucose IV); give oxygen to a target saturation; treat pain (paracetamol 1 g PO/IV 6-hourly, maximum 4 g/24 h in adults ≥50 kg, 15 mg/kg per dose in children to 60 mg/kg/24 h; morphine 1–2 mg IV titrated every 5 minutes in adults, 0.05–0.1 mg/kg IV in children); return hearing aids, glasses and dentures; use a professional interpreter, not a relative, for any serious decision.Doctor / Nurse
• Treat without consent in an emergency where the patient cannot consent (unconscious, seizing, shocked, delirious or intoxicated to incoherence) and delay while surrogates are contacted would jeopardise life or health; record why the patient could not consent, the harm delay would have caused, and that no valid advance refusal was known.
• Where capacity is absent, work through a fixed sequence: (1) can the decision safely wait — postpone if the impairment is fluctuating or reversible; (2) is there a valid and applicable advance decision (refusal of life-sustaining treatment must be written, witnessed, and state it applies even where life is at risk; any ambiguity — the presumption is to save life); (3) is there a lawfully appointed proxy — follow their decision; (4) otherwise act in best interests, asking those close to the patient what the patient valued, feared and previously said.
• Handle refusal and departure against advice properly: address reversible reasons first (pain, nicotine withdrawal, dependants, cost, fear), assess and record capacity for that specific decision, explain the risk in concrete terms, offer the best available compromise with written safety-netting and an explicit welcome to return. If the patient declines to sign a refusal form, record that it was offered and declined and who witnessed. A patient who lacks capacity cannot self-discharge.
• Before any sedative, exclude the medical causes of agitation (hypoglycaemia, hypoxaemia, head injury, sepsis, withdrawal, poisoning, hyperthermia, retention, pain), check capillary glucose and SpO2, and have oxygen, suction, a bag–valve–mask and a benzodiazepine antagonist to hand; monitor SpO2, respiratory rate, pulse and BP continuously until rousable and stable, with an ECG when practicable as antipsychotics prolong the QT. Physical restraint never to the neck, chest or abdomen, never prone.Doctor / Nurse
• Reverse what you cause: acute dystonia — procyclidine 5–10 mg IM/IV; benzodiazepine respiratory depression — support ventilation first, then flumazenil 200 micrograms IV over 15 seconds followed by 100 micrograms at 60-second intervals to a usual maximum of 1 mg (reserved for significant compromise, avoided where seizures or tricyclic co-ingestion are likely); opioid respiratory depression — naloxone 100–400 micrograms IV titrated in adults, 10 micrograms/kg IV in children.Doctor / Nurse
• Write the note at the bedside with a time on it: date, 24-hour time, full name, signature and designation; facts and reasoning, not conclusions ("states he was struck on the head with a stick", not "assault"), the patient's own words in quotation marks, and relevant negatives. Describe injuries by site, size in centimetres, shape, edges, colour and depth on a body diagram — no opinions on weapon, direction, sequence or age. Correct an error with a single line, the correction beside it, timed, dated and signed; never alter a record.
• Confirm death personally and refer, do not certify, where the death may be unnatural: no response to voice or pain, no central pulse and no heart sounds over a sustained period, no respiratory effort, fixed unreactive pupils — an asystolic trace supports but does not replace examination. Deaths following injury, poisoning, burns, drowning, hanging, alleged assault, in custody, during or shortly after a procedure, or of unknown cause are referred. When something goes wrong, disclose: explain, apologise, remedy and report — an apology is an expression of regret, not an admission of negligence.